Transcript NEW IVF PATIENT`S LECTURE

THE LEEDS CENTRE FOR REPRODUCTIVE MEDICINE
SEACROFT HOSPITAL
Version 1.1: January 2010
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Explain the treatment process
 Clinical
 Laboratory
 Nursing
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Highlight risks in treatment
 OHSS
 Multiple pregnancy
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Factors affecting outcome
Increase awareness of protocols
Information regarding research projects
Normal menstrual cycle control
Growth of the egg and
womb lining
Ovulation and womb
support
FSH
LH
Oestrogen
Progesterone
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Why do we need to make changes?
 We need more than one egg in the cycle
 Not all eggs fertilise or grow
 Not all embryos have a good potential for
development
 We want to transfer 1-3 embryos for a good
success rate
 We do not want the gland in the brain to become
confused in treatment
 Long Protocol
 Flare Protocol
 Short Protocol
1.
Suppression of the natural cycle
To switch off the gland in the brain so that it does not interfere in
treatment
2. Stimulation
Hormone injections to produce multiple eggs
3. Ovulation trigger or HCG injection
4. Egg collection
5. Embryo transfer
6. Hormonal support after the embryo transfer
Oral Contraceptive Pill
Prostap once a month injection
OR
Buserelin daily injection
OR
Nafarelin three times a day nasal spray
Side effects
headaches, hot flushes, night sweats, mood-swings,
prolonged period or second bleeding
Ovary
Uterus
Dose of stimulation is adjusted for:
Reserve of eggs in the Ovary (hormone levels and scan findings)
Age
Weight or Body Mass Index
Past history (infections, cyst removal)
Presence or absence of PCOS
Types:
Menopur, Merional, Puregon,
Gonal-F, Fostimon
All are subcutaneous injections
x
x
x
x
HCG injection
Pregnyl (commonest)
Ovitrelle
Recombinant LH
Timed 36 hours prior to egg collection
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Performed under ultrasound guidance
Fast acting sedation & analgesia
Duration 20 - 45 minutes
Out-patient based
Return home after 2-3 hours
Need care after returning home
DO NOT DRIVE OR OPERATE MACHINERY
Common Symptoms
 mild discomfort for 1 - 3 days
(Paracetamol suppository)
 slight discharge
 “hang-over” effect
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Sperm production
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Insemination of Eggs or Sperm injection into the
eggs
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Fertilisation check
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Observation of growth
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Selection of embryos for transfer
Requires a full bladder
Performed under ultrasound guidance
After Embryo Transfer:
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Hormone support:
 Mainly Progesterone
 Some HCG (with low risk)
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Pregnancy test 14-16 days later
Worried
Please contact US
Risk: Multiple embryos =
in multiple pregnancy rate
Our Objectives:
1.
2.
To maximise the pregnancy rate
To reduce the risk of a multiple pregnancy
Before you think “great, a twin pregnancy! We have
our family completed in one go!”
Let us look at the facts of the next slide...
Risk
Twins
Triplets
Average Duration of Pregnancy (Term = 40 weeks)
37 weeks
34 weeks
Proportion of premature low birth weight infants
50%
90%
Neonatal death (1st week of life)
5 x higher
9 x higher
Postnatal cerebral palsy
4 x higher
18 x higher
Maternal pre-eclampsia
3 x higher
9 x higher
Maternal diabetes
2-3 x higher
2-3 x higher
Maternal coronary heart disease
2 x higher
2 x higher
Maternal death from cardiovascular causes
7-11 x higher
7-11 x higher
Maternal death (overall)
2 x higher
2 x higher
We consider SET in:
 Women < 35 years
 First treatment cycle
 When fertilisation and growth of
embryos is satisfactory
 When there are spare embryos for
freezing
Day 2, 3 or 5
Objective:
 Select the best embryo at the earliest opportunity
Choice is dependent upon:
 Total number of embryos available
 Quality of embryos
Please trust us to do the BEST in your cycle
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Cyst formation during the suppression phase
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Risk of cycle being abandoned (Poor or Excessive response)
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On the day of egg collection
 No eggs (<1%)
 Not being able to give a sperm sample (anxiety, stress, very
(5-10%)
low counts, poor testicular function)
 Back up freezing or Emergency PESA
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After egg collection
 Complete fertilisation failure (3-5%)
 Failure of growth of embryos (<5%)
 Failed embryo transfer (very rare ; one a year)
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Infection
 Pre-treatment swabs
 Dalacin cream
 Cleaning the vagina
 Sterile environment
 “No touch technique”
 Antibiotic in flush
 Prophylactic antibiotic
in “at risk cases”
RARE
Version 2: March 2008: VS / EB
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Injury to bowel
leading to internal
infection RARE
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Injury to blood vessel
leading to internal
bleeding
RARE
The risk is highest after the ovulation trigger and if
you become pregnant
Who is at a higher risk?
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Women with polycystic ovaries
Young women < 30 years
Severe OHSS is RARE (1-2%). However this is
because we monitor everybody ‘at risk’
ANY CONCERNS:
Contact the Emergency On-Call phone
 Miscarriage (15-20%)
 Ectopic pregnancy (3-4%)
 Multiple pregnancy (25%)
Version 2: March 2008: VS / EB
Age (years)
PESA
MESA
 Anonymity Laws
 Scarcity
 Recruiting known donor
Version 2: March 2008: VS / EB
Egg Collection
Preparation of sperm sample
Insemination (IVF) or sperm injection
(ICSI)
Fertilization check
Embryo Transfer
Freezing
Looking for the eggs
A human egg in its surrounding cells
A tenth of a millimeter
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Produced in unit by
masturbation
Sterile specimen pot
Witnessing procedures
In vitro fertilisation: IVF
Intra cytoplasmic sperm injection:
ICSI
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Only mature eggs can be injected (usually
~70%)
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Around 10% will be damaged by the injection
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Pregnancy rates are the same as for IVF
Fertilisation
overnight
Version 2: March 2008: VS / EB
next day
Normally fertilised egg
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Usually around 60% of eggs will fertilise
normally
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A proportion may be unfertilised, abnormally
fertilised or non-viable, these eggs cannot be
selected for treatment
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Patients will be telephoned the day after egg
collection
Embryonic Development
2 cells
Early day 2
4 cells
8 cells
Late day 2
Day 3
Morula
Blastocyst
Day 4
Day 5
Good
Poor
fragmentation
unevenness of cells
cell numbers
 Embryos for transfer selected
(consents checked)
 Spare embryos may be
- frozen
- or placed into extended culture with a view
to freezing
(depending on quality)
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Stresses of infertility and infertility
treatment
HFEA Code of Practice requires all units to
offer counselling as a normal part of
treatment
Types of counselling
Arranging an appointment
Confidentiality
Both Partners:
 Healthy life style
 No Smoking
 Female: Avoid alcohol altogether
 Male: maximum of 12 units per week
Female Partner:
 Good diet and normal body weight
 Up to date cervical smear
 Folic acid 400 mcgs daily
 Rubella
Tight schedule
Please arrive promptly for appointments
Allow plenty of time for parking
Please ring unit if late or unable to attend to give us time
to reschedule appointments
Be sure you know what to do next
before leaving the Unit
Both partners must attend the nurse
consultation session
Bring a passport sized photo of both
partners and think of a password
Photo ID (passport or driving licence)
HFEA Registration
 Welfare of the child
 Communication consent
 GP letters
 Information check list
 Trust consents to treatment
 number of embryos to be transferred
 observation and freezing of spare embryos
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IVF /and ICSI consent
Use of donor sperm / eggs
Embryo research
HFEA forms – use of eggs, sperm and
embryos
 embryo freezing
 fate of sperm and embryos in the event of
death or mental incapacity – disposal,
research or posthumous use
1.NHS
2.Self-Funding or Private
Payment
If you are paying for your own treatment, payment must be
made at the consultation appointment
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cash
cheque
credit card
Homecare dispensary service for all patients
Pharmacy (prescription charge is payable)
Injections
Need to consider
 self/partner injection
 GP/Practice nurse
 Daily attendance to ACU/Gynae ward
 9-10 visits over 6 weeks
 2-3 months
LCRM working hours - 8.30am - 5.00pm (0113 2063100)
In an emergency...
Out of hours weekdays (5pm until 8am) and weekends - A
team member can be reached on a mobile phone via St
James’s switchboard (0113 2433144)
Please try to contact staff during working hours as at other
times they are not in the hospital and do not have access to
your notes or the appointment diaries.
Support Line –
www.lacu-patient2patient.org.uk